Low back pain
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Low back pain

Also listed as: Back pain - low

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment
Special Considerations
Supporting Research
  

Low back pain is one of the most common problems people have. About 60 - 80% of the adult U.S. population has low back pain, and it is the second most common reason people go to the doctor. Low back problems affect the spine's flexibility, stability, and strength, which can cause pain, discomfort, and stiffness.

Back pain is the leading cause of disability in Americans under 45 years old. Each year 13 million people go to the doctor for chronic back pain. The condition leaves about 2.4 million Americans chronically disabled and another 2.4 million temporarily disabled.

Most back pain can be prevented by keeping your back muscles strong and making sure you practice good mechanics (like lifting heavy objects in a way that won’t strain your back).

Signs and Symptoms

Symptoms of low back pain may include:

  • Tenderness, pain, and stiffness in the lower back
  • Pain that spreads into the buttocks or legs
  • Having a hard time standing up or standing in one position for a long time
  • Discomfort while sitting
  • Weakness and tired legs while walking

What Causes It?

Low back pain is usually caused by and injury -- strain from lifting, twisting, or bending. However, in rare cases low back pain can be a sign of a more serious condition, such as an infection, a rheumatic or arthritic condition, or a tumor.

A ruptured or bulging disk -- the strong, spongy, gel-filled cushions that lie between each vertebra -- and compression fractures of the vertebra, caused by osteoporosis, can also cause low back pain. Arthritis can cause the space around the spinal cord to narrows (called spinal stenosis), leading to pain.

Risk factors for back pain include age, smoking, being overweight, being female, being anxious or depressed, and either doing physical work or sedentary work.

What to Expect at Your Provider's Office

Often your doctor will be able to diagnose your back pain with a physical exam. Your doctor will ask you to stand, sit, and move. Your doctor will check your reflexes and perhaps your response to touch, slight heat, or a pinprick. Depending on what your doctor finds, other tests may include an X-ray, a magnetic resonance imaging (MRI) scan, a bone scan, and computed tomography (CT) scan.

Treatment

In many cases back pain will get better with self-care. You should see your doctor if you pain doesn’t get better within 72 hours. You can lower your risk of back problems by exercising, maintaining a healthy weight, and practicing good posture. Learning to bend and lift properly, sleeping on a firm mattress, sitting in supportive chairs, and wearing low-heeled shoes are other important factors. Although you may need to rest your back for a little while, staying in bed for several days tends to make back pain worse.

For long-term back pain, your doctor may recommend stronger medications, physical therapy, or surgery. Most people will not need surgery for back pain.

Medications used to treat low back pain include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil) and naproxen (Aleve), muscle relaxants such as carisoprodol (Soma), and steroids such as prednisone. Your doctor may prescribe opiates such as hydrocodone (Lortab, Vicodin) for short-term use. An injection of a corticosteroid (cortisone shot) may also help decrease inflammation.

Complementary and Alternative Therapies

Alternative therapies can help ease muscle tension, correct posture, relieve pain, and prevent long-term back problems by improving muscle strength and joint stability. Many people find pain relief by using hot and cold packs on the sore area. Special exercises, such as ones designed for your specific problem by a physical therapist, can help strengthen your core abdominal muscles and your back muscles, reducing pain and making your back stronger.

Nutrition and Dietary Supplements

There is no special diet for back pain, but you can help keep your body in good shape by eating a healthy diet with lots of fruits, vegetables, and whole grains. Choose foods that are low in saturated fat and sugar. Drink plenty of water.

Foods that are high in antioxidants (such as green leafy vegetables and berries) may help fight inflammation.

Avoid caffeine and other stimulants, alcohol, and tobacco.

Exercise moderately at least 30 minutes daily, 5 days a week. Get your health care provider to okay you for exercise before starting a regimen.

These supplements may help fight inflammation and pain:

  • Omega-3 fatty acids, such as flaxseed and fish oils, 1 - 2 capsules or 1 tablespoonful oil daily, to help decrease inflammation. Omega-3 fatty acids can increase the risk of bleeding and potentially interfere with blood-thinning medications such as warfarin (Coumadin) and aspirin.
  • Glucosamine/chondroitin, 500 - 1,500 mg daily. In some studies, glucosamine and chondroitin have helped relieve arthritis pain. It has not been studied specifically for low back pain. People with allergies to shellfish should not use glucosamine. There are some concerns that chondroitin may worsen asthma symptoms. Glucosamine and chondroitin may interact with blood-thinning medications such as warfarin (Coumadin) and aspirin.
  • Methylsulfonylmethane (MSM), 3,000 mg twice a day, to help prevent joint and connective tissue breakdown. In some studies, MSM has been shown to help relieve arthritis pain.
  • Bromelain, 250 mg twice a day. This enzyme that comes from pineapples reduces inflammation. Bromelain may increase the risk of bleeding, so people who take anticoagulants (blood thinners) should not take bromelain without first talking to their health care provider. People with peptic ulcers should avoid bromelain. Turmeric is sometimes combined with bromelain, because it makes the effects of bromelain stronger. Bromelain may interact with some antibiotic medications.

Herbs

Herbs are generally available as standardized, dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1 - 2 heaping teaspoonfuls/cup water steeped for 10 - 15 minutes (roots need longer).

  • Turmeric (Curcuma longa) standardized extract, 300 mg three times a day, for pain and inflammation. Turmeric is sometimes combined with bromelain because it makes the effects of bromelain stronger. Turmeric can increase the risk of bleeding, especially for people who take blood-thinning medication. Ask your doctor before taking turmeric.
  • Devil's claw (Harpagophytum procumbens) standardized extract, 100 - 200 mg one to two times daily. Devil’s claw has been used traditionally to relieve pain. One study found that more than 50% of people with osteoarthritis of the knee or hip or low back pain who took devil’s claw reported less pain and better mobility after 8 weeks. Devil’s claw may increase the risk of bleeding and interact with diabetes medications, so tell your health care provider before taking it if you also take blood-thinning medication or if you have diabetes. Devil's claw can affect the heart and may not be right for people with certain heart problems. It can also potentially be problematic for people with gallstones.
  • Willow bark (Salix alba) standardized extract, 500 mg up to three times daily, to relieve pain. Willow acts similar to aspirin. Do not take white willow if you are also taking aspirin or blood-thinning medications. Check with your health care provider if you are allergic to aspirin or salicylates before taking white willow. Do not give Willow should to children under the age of 18.
  • Capsaicin (Capsicum frutescens) cream, applied to the skin (topically). Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the skin, it is believed to temporarily reduce amounts of “substance P,” a chemical that contributes to inflammation and pain. One found a topical capsaicin cream relieved pain better than placebo in 320 people with low back pain. Pain reduction generally starts 3 - 7 days after applying the capsaicin cream to the skin.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following treatments to relieve low back pain based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Some of the most common remedies for this condition are listed below:

  • Aesculus -- for dull pain with muscle weakness
  • Arnica montana -- especially with pain as a result of trauma
  • Colocynthis -- for weakness and cramping in the small of the back
  • Gnaphalium -- for sciatica that alternates with numbness
  • Lycopodium -- for burning pain, especially with gas or bloating
  • Rhus toxicodendron -- for stiffness and pain in the small of the back

Hydrotherapy

Contrast hydrotherapy -- alternating hot and cold -- may help. Alternate 3 minutes hot with 1 minute cold. Repeat three times to complete one set. Do two to three sets per day.

Castor Oil Packs

Apply oil directly to skin, cover with a clean soft cloth and plastic wrap. Place a heat source over the pack and let sit for 30 - 60 minutes. Repeat this procedure for 3 consecutive days.

Acupuncture

Reviews of clinical studies have found that acupuncture may be effective for low back pain. In addition, acupuncturists frequently report success in treating low back pain, and the National Institutes of Health recommend acupuncture as a reasonable treatment option. An acupuncturist may use a comprehensive approach including specialized massage, warming herbal oils, and patient education.

Treating low back pain with acupuncture can be complex because many meridians (including the kidney, bladder, liver, and gallbladder) affect this area of the body. Treatment of the painful areas and related sore points is often done as well, with needles or moxibustion (burning the herb mugwort over specific acupuncture points).

A study using acupuncture to treat 1,162 patients with a history of chronic low back pain found that at 6 months, low back pain was better after acupuncture treatment -- almost twice as better than from conventional therapy. Patients had ten 30-minute acupuncture sessions, generally two sessions per week.

Chiropractic

According to a comprehensive review conducted by the Agency for Healthcare Research and Quality, spinal manipulation and NSAIDs are the two most effective treatments for acute low back pain. Of these, only spinal manipulation was judged to both relieve pain and restore function. Spinal manipulation also appears to be effective for chronic low back pain, but the evidence is less conclusive.

Massage

Massage may help treat and prevent short and long-term back problems.

Yoga and Tai Chi

There is evidence that suggests that the mind-body practices of yoga and tai chi offer significant relief of the symptoms of low back pain.

Special Considerations

Chronic low back problems can interfere with everyday activities, sleep, and concentration. Severe symptoms may affect mood and sexuality. Chronic pain is also associated with depression, which can in turn make chronic pain worse.

Supporting Research

Aota Y, Iizuka H, Ishige Y, et al. Effectiveness of a lumbar support continuous passive motion device in the prevention of low back pain during prolonged sitting.Spine. 2007;32(23):E674-7.

Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, Grimm RH Jr, Owens EF Jr, Garvey TA, Transfeldt EE. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J. 2011;11(7):585-98.

Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, Macchi C. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clin Rehabil. 2010;24(1):26-36. 

Chan CW, Mok NW, Yeung EW. Aerobic exercise training in addition to conventional physiotherapy for chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011;92(10):1681-5.

Cherkin DC, Eisenberg D, Sherman KJ, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med. 2001;161:1081-1088.

Cherkin DC, Sherman KJ, Kahn J, Wellman R, Cook AJ, Johnson E, Erro J, Delaney K, Deyo RA. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011;155(1):1-9.

Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93. Review.

Chou R, Huffman LH. American Pain Society, American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-14.

Chrubasik S, Eisenburg E, Balan E, Weinberger T, Luzzati R, Conradt C. Treatment of low back pain exacerbations with willow bark extract: a randomized double blind study. Am J Med. 2000;109:9-14.

Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. 2007 Jul;21(7):675-83. Review.

Cuesta-Vargas AI, García-Romero JC, Arroyo-Morales M, Diego-Acosta AM, Daly DJ. Exercise, manual therapy, and education with or without high-intensity deep-water running for nonspecific chronic low back pain: a pragmatic randomized controlled trial. Am J Phys Med Rehabil. 2011;90(7):526-34; quiz 535-8.

Dufour N, Thamsborg G, Oefeldt A, Lundsgaard C, Stender S. Treatment of chronic low back pain: a randomized, clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises. Spine (Phila Pa 1976).2010;35(5):469-76.

Eisenberg DM, Post DE, Davis RB, et al. Addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial. Spine. 2007;32(2):151-8.

Engbert K, Weber M. The effects of therapeutic climbing in patients with chronic low back pain: a randomized controlled study. Spine (Phila Pa 1976).2011;36(11):842-9. 

Gagnier JJ, van Tulder M, Berman B, Bombardier C. Herbal medicine for low back pain. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004504. Review.

Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167(17):1892-8.

Hall AM, Maher CG, Lam P, Ferreira M, Latimer J. Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial. Arthritis Care Res (Hoboken).2011;63(11):1576-83. doi: 10.1002/acr.20594. 

Harden RN, Remble TA, Houle TT, Long JF, Markov MS, Gallizzi MA. Prospective, randomized, single-blind, sham treatment-controlled study of the safety and efficacy of an electromagnetic field device for the treatment of chronic low back pain: a pilot study. Pain Pract. 2007;7(3):248-55.

Henochoz Y, de Goumoens P, Norberg M, et al. Role of physical exercise in low back pain rehabilitation: a rondomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation. Spine (Phila Pa 1976). 2010;35(12):1192-9.

Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther. 2004 Jul-Aug;27(6):388-398.

Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative Physiol Ther. 2009 Jun;32(5):330-43.

Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. [Review]. Pain Pract. 2010;10(2):94-102.

Hu S. Review: surgery may be more effective than unstructured nonoperative treatment for chronic low-back pain. J Bone Joint Surg Am. 2007;89(11):2558.

Inoue M, Hojo T, Nakajima M, Kitakoji H, Itoi M. Comparison of the effectiveness of acupuncture treatment and local anaesthetic injection for low back pain: a randomised controlled clinical trial. Acupunct Med. 2009 Dec;27(4):174-7.

Jones MA, Stratton G, Reilly T, Unnithan VB. Recurrent non-specific low-back pain in adolescents: the role of exercise. Ergonomics. 2007;50(10):1680-8.

Keller A, Hayden J, Bombardier C, van Tulder M. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur Spine J. 2007; [Epub ahead of print].

Kelly RB. Acupuncture for pain. Am Fam Physician. 2009 Sep 1;80(5):481-4.

Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD003008. Review.

Kim JI, Kim TH, Lee MS, Kang JW, Kim KH, Choi JY, Kang KW, Kim AR, Shin MS, Jung SY, Choi SM. Evaluation of wet-cupping therapy for persistent non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot trial. Trials. 2011;12:146.

Kluge J, Hall D, Louw Q, Theron G, Grové D. Specific exercises to treat pregnancy-related low back pain in a South African population. Int J Gynaecol Obstet. 2011;113(3):187-91.

Mannion AF, Balague F, Pellise F, Cedraschi C. Pain measurement in patients with low back pain. Nat Clin Pract Rheumatol. 2007;3(11):610-8.

Marras WS, Ferguson SA, Burr D, Schabo P, Maronitis A. Low back pain recurrence in occupational environments. Spine. 2007;32(21):2387-97.

Mens JM. The use of medication in low back pain. Best Pract Res Clin Rheumatol. 2005 Aug;19(4):609-621.

Mohseni-Bandpei MA, Rahmani N, Behtash H, et al. The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. J Bodyw Mov Ther. 2011;15(1):75-81.

Mulholland RC. Scientific basis for the treatment of low back pain. Ann R Coll Surg Engl. 2007;89(7):677-81.

Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions for subacute low back pain. Clin Rehabil. 2002;16(8):811-20.

Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 2006;6(2):131-7.

Sherman KJ, Cherkin DC, Connelly MT, Erro J, Savetsky JB, Davis RB. Complementary and alternative medicine medical therapies for chronic low back pain: What treatments are patients willing to try? BMC Complement Altern Med. 2004; Jul 19;4:9.

Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, Deyo RA. A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain. Arch Intern Med. 2011;171(22):2019-26. 

Smith L, Oldman AD, McQuay HJ, Moore RA. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain. 2000;86:119-32.

Tilbrook HE, Cox H, Hewitt CE, Kang'ombe AR, Chuang LH, Jayakody S, Aplin JD, Semlyen A, Trewhela A, Watt I, Torgerson DJ. Yoga for chronic low back pain: a randomized trial. AnnIntern Med. 2011;155(9):569-78. 

Trigkilidas D. Acupuncture therapy for chronic lower back pain: a systematic review. [Review]. Ann R Coll Surg Engl. 2010;92(7):595-8.

van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. [Review]. Eur Spine J. 2011;20(1):19-39.

Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil. 2009 Jan;23(1):3-14. Review.

Walsh AJ, O'neill CW, Lotz JC. Glucosamine HCl alters production of inflammatory mediators by rat intervertebral disc cells in vitro. Spine J. 2007;7(5):601-8.

Witt CM, Lüdtke R, Baur R, Willich SN. Homeopathic treatment of patients with chronic low back pain: A prospective observational study with 2 years' follow-up. Clin J Pain. 2009 May;25(4):334-9.


Review Date: 1/20/2012
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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